18 PUBLIC HEALTH SERVICE. Estimate of physical improvement of patients treated for hookworm disease.-Professional educators have repeatedly expressed a desire to have at their disposal statements of a mathematical nature that can be used to express the effects of hookworm disease upon the mental and physical status of school children. In response to requests of this kind the division of zoology of the Hygienic Laboratory undertook a piece of cooperative work with the Rockefeller Sanitary Commission. The mental studies were conducted under the direction of Prof. Edward K. Strong, jr., and financed by the Rockefeller Commission. The physical and zoological studies were conducted under the direction of Prof. C. W. Stiles, as part of his regular official work; part of the physical studies were financed by the Rockefeller Commission. The detailed studies will be issued later as a joint report by Profs. Strong and Stiles. One hundred and fifteen children were tabulated in the final results. They were examined physically and their condition was recorded; 186 characters were found to lend themselves more or less satisfactorily to comparison. These characters were summarized for each of the five groups that were later adopted and percentages were drawn to represent each of these characters for each one of the groups. These percentages were compared and the groups were classified in first, second, third, fourth, and fifth places in respect to each character; each place (1 to 5) was given a rating of 10 points for first place down to 2 for fifth place, and the total scores were compared. Certain of the children were placed under treatment while others were not treated, and some weeks later the examinations were repeated and improvements noted. The total number of score points was 5,580, and the theoretical maximum score any group could possibly obtain was 1,860 points. The uninfected children (23 in number, group A) scored first place in the competition with 1,498 points (80 per cent of theoretical maximum) in the earlier examination; in the last examination this group fell to second place with 1,292 points (69 per cent of theoretical maximum). The infected children who were untreated (12 in number, group B) won third place with 1,102 points (59 per cent of theoretical maximum) in the first test; in the last test they fell to fifth place with 849 points (46 per cent of theoretical maximum). The infected children who were completely cured (36 in number, group C) won second place with 1,242 points (67 per cent of theoretical maximum) in the test conducted before treatment; in the last test, conducted after treatment, during which an average of 40.2 hookworms was collected from each patient, they advanced to first place with 1,366 points (73 per cent of theoretical maximum). Thus this group actually surpassed the uninfected group (A) by 4 per cent. The infected children who were treated, but who upon final microscopic examination were found to be incompletely cured (32 in number, group D), won fifth place with 826 points (44 per cent of theoretical maximum) on the first test; during treatment an average of 93.4 hookworms per patient was collected from this group, which then, on the final test, advanced to fourth place with 984 points (53 per cent of theoretical maximum). A group of infected children (12 in number, group E) was treated and an average of 100.2 hookworms per patient was collected, but it was impossible to determine whether all the worms were expelled. This group won fourth place with 919 points (49 per cent of theoretical maximum) before treatment; it advanced to third place with 1,089 points (59 per cent of theoretical maximum) after treatment. Comparing these 5 groups, in this manner, similarly to the comparisons made in intercollegiate athletic contests, they may be conceived as representing 5 communities that are competing for 5,580 units of value with a theoretical maximum of 1,860 points per community. All hookworm communities advanced after they were treated (C. D. E.), and one of these (C) actually outstripped another community (A) in which hookworm infection was not originally found; but when left untreated 1 community (B) fell backward in the results of competition. Broadly speaking, the statistics given may be taken as a comparative indication of the physical efficiency of the 5 communities. In physical improvement many changes were noticed, but it was particularly the circulatory and respiratory systems in which treatment resulted in strikingly favorable changes. Other improvements were in height, weight, lung capacity, complexion, texture of hair, etc. General results of measures against hookworm disease.-The campaign against hookworm disease in this country has undoubtedly resulted in the cure of numerous patients, in a widespread knowledge of the disease, in a greatly increased interest on the part of the laity in the subject of public health, in an improvement of some of the public-health regulations, in a greatly increased amount of instruction in the public schools along public-health lines, in increased publichealth appropriations, and in an improvement in public-health organizations. It has not, however, as yet resulted in the improvement in rural sanitation that was hoped for. This latter part of the work has, in reality, only begun, and the efforts in this direction must be increased. INVESTIGATIONS OF MALARIA. The antimalarial work has been continued and extended during the year, and efforts have been made to systematize it and increase its usefulness. The general office and laboratories formerly located at Mobile, Ala., were transferred in November, 1914, to the marine hospital at New Orleans, La., where facilities for the conduct of the investigations are more advantageous. Asst. Surg. Gen. H. R. Carter was in charge of all the antimalarial work until August 1, 1914, when he was relieved by Surg. R. H. von Ezdorf on the latter's return from Vera Cruz, Mexico. Subsequently Asst. Surg. Gen. Carter has been in charge of the studies on the relation of impounding reservoirs to the prevalence of malaria, which remains a special investigation, assisted, however, by members of the general force. This is composed of the following persons: Asst. Surg. R. C. Derivaux, Sanitary Engineer J. A. A. Le Prince, Technical Assistants H. A. Taylor and M. B. Mitzmain, and Asst. Epidemiologist T. H. D. Griffitts. As in previous years, the investigations have been conducted in cooperation with the health authorities of the States and localities concerned. The work so far accomplished or in progress may be classified under the following headings: Collection of morbidity data, malaria surveys, demonstration work, scientific field and laboratory studies, educational campaign, and special studies of impounded waters, rice culture, and drainage projects. MORBIDITY REPORTS. By means of circulars to health authorities and physicians, an effort has been made to obtain information in regard to the prevalence and geographic distribution of malaria. The reports thus received showed a total of 204,881 cases reported during the year 1914 in the States of Alabama, Arkansas, Florida, Kentucky (six months), Louisiana (eight months), Mississippi, North Carolina, South Carolina, Tennessee, and Virginia (six months). The information so far accumulated seems to indicate that in the Southern States, with an estimated population (excepting Texas) of over 20,000,000, at least 4 per cent of the inhabitants suffer annually an attack of malaria. The duty of compiling the morbidity reports of malaria on receipt in the bureau has since February, 1915, been placed in charge of the Division of Sanitary Reports and Statistics, to which it properly belongs. SURVEYS. Surveys of breeding places of Anopheles, together with a study of the geographic and climatic conditions, social, hygienic, and economic conditions, and the prophylactic measures best applicable for the control of malaria, were made in 34 selected localities, as follows: Alabama: Mobile. Arkansas: Altheimer, Arkansas City, Blissville, Blytheville, Brinkley, Clarendon, Mississippi: Electric Mills, Greenville. North Carolina: Roanoke Rapids. South Carolina: Eau Claire, Greenville, Hartsville, Rock Hill, Sumter. These surveys have been of great value in the study of life and habits of anopheline mosquitoes. The observations made include the extent and selection of breeding places; species of anophelines; local conditions favorable and unfavorable for breeding of anophelines; hiding and resting places; distance of flight; biting time; migration, if any; effects of topography and vegetation on flight; importance of freight cars in the distribution of Anopheles; effects of temperature and wind at different seasons of the year. Of especial interest has been the study of the extent of the effect of industrial wastes which might be utilized for Anopheles mosquito control, such as the wastes from gas plants, the dye and bleaching wastes from mills, sawdust and shavings from lumber mills, salt-water washings from ice plants, sewage discharges in streams; house wastes, such as ashes and garbage; and the effects of artesion-well waters having varying contents of salts and sulphureted hydrogen. In addition, the effects of fish, water insects, such as water boatmen, plant life, such as aquatic plants forming "water shield," are being observed. At all places where surveys were made a number of specimens of mosquitoes was collected and forwarded to Dr. L. O. Howard, consulting entomologist, United States Public Health Service, Washington, D. C., for the official determination of the species. Acknowledgment is hereby made for the valuable assistance rendered by him in this part of the work. Many species have been determined, of which number a few are more or less definitely known to act as hosts for the transmission of the malarial parasite. Frederick Knab gives a list of 34 species of American Anopheles, of which number 8 have been definitely shown to serve as hosts for the malarial parasite. These are: Anopheles albimanus. argyritaris. intermedium. Anopheles pseudomaculipes. pseudopunctipennis. The most common species encountered in the Southern States where surveys have been made are Anopheles crucians, quadrimaculatus, and punctipennis. The last named, Anopheles punctipennis, is not considered to be a transmitter of malaria. Anopheles crucians, according to experiments by Beyer and his coworkers, is said to be a transmitter of the estivo-autumnal parasite only, but this needs confirmation. It is evident from this that Anopheles mosquitoes may be present and yet no malaria prevail, and again, the prevailing species may determine the type of malaria. Anopheles quadrimaculatus will transmit all three types of malarial parasites, and this species is the one most commonly found in the Southern States where malaria prevails. In most of the places where surveys were made, a report of conditions, together with recommendations for the abatement of mosquito-breeding places, was submitted to the mayor and local health officer. These recommendations were generally based upon advice of Sanitary Engineer J. A. A. Le Prince. No antimalarial campaign can be successfully and economically conducted without making surveys on the lines given. Antimosquito measures.-The measures generally recommended are, briefly, the following: (a) Regrading and training of streams, creeks, or similar natural watercourses so as to favor a free current. (b) Drainage for the removal of standing water or to produce a movement of water unfavorable to mosquito breeding. (c) Filling in of low places that are too low to drain or which can not be drained economically. (d) Oiling and larvacides. (e) Natural enemies: Stocking with top-feeding minnows is a measure applicable in certain ditches, ponds, pools, swamps, streams, and many other bodies of water. DEMONSTRATION WORK. As a result of surveys made, the following communities have undertaken active antimosquito work with especial reference to eradicating or controlling malarial fever: Roanoke Rapids, N. C.-Following surveys made by Asst. Surg. Gen. H. R. Carter and Surg. R. H. von Ezdorf, in 1913, Dr. T. W. M. Long, a physician in the employ of several mills, secured a fund amounting to $3,600 for antimalarial work. The following is a summary of the work done and cost of same: 6 miles of ditching, clearing, and removal of cans, etc_ 3,000 gallons of oil___ Inspection and maintenance $2,931. 37 293. 20 323. 48 3, 548. 05 Another survey was made in October, 1914, one year after the first, and as a result of the work anopheline-breeding places had been eliminated and no breeding was found. The malaria index as shown by blood examinations in 1913 was 13.75 per cent and in 1914 was 4.4 per cent, a decrease of 9.35 per cent, equal to a reduction in the incidence of malaria of 67.7 per cent in the one year. It was reported by Dr. Long that 95 per cent of the cases of malaria which occurred during the year 1914 were relapses. It is understood that a fund of $1,500 has been raised for the continuation of the work during the present year. Electric Mills, Miss.-Upon the request of Dr. Cecil Champenois for assistance in his antimalarial operations a survey was made and an index taken during May, 1914, and again in April, 1915. Some ditching, filling, and oiling were done, and an apparent reduction was noted in the incidence of the disease. The malarial index in 1914 was 11.7 per cent and for 1915 was 3.8 per cent, a reduction of 7.9 per cent, or an improvement of 67.5 per cent in the one year. The cost of maintenance of the work during the past three years was estimated to be $1,000. Other active antimalarial campaigns have been conducted as a result of surveys made at the following places: Hartsville, S. C., drainage and oiling. Greenville, S. C., drainage. Stuttgart, Ark., screening. Brunswick, Ga., drainage and filling. Brinkley, Ark., educational. Emporia, Va., ditching. Cummins, Ark. Here is located the State penitentiary. The commissioners will carry out measures of drainage and screening which were outlined in a written report made by Sanitary Engineer Le Prince, after a survey there in May, 1915. At Lock 12 on the Coosa River, a camp of the Alabama Power Co., a survey was made and a malarial index taken in October, 1914, and again in May, 1915. The officials of the Alabama Power Co. have employed a physician to look after the sanitation and health of this camp and will carry out recommendations that were made with reference to quinine prophylaxis and screening. |